- Email: [email protected]
Issues Associated with Infection Control and Prevention in Nursing Homes in Japan
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Poster Abstracts / American Journal of Infection Control 42 (2014) S29-S166
Post-discharge search is recommended by national legislation (RDC February 8, 2009) so as to identify mycobacterial infections after videosurgeries, conventional abdominal and pelvis surgeries, breast surgeries and liposuctions. This search was performed by telephone, using a standard questionnaire with signs and symptoms suggesting infection. After SSI was identified, the patient was informed and followed after 60 and 90 days to follow on outcome. RESULTS: 282 SSI were identified in intra-hospital environment and 104 cases were identified through post-discharge search, i.e., from the total SSI, 26.9% would not be noticed if there was not a post-discharge search. No case with suspected mycobacterial infection was identified. From 13245 patients undergoing surgery, 11968 (90.4%) were found and accepted to answer the questionnaire, showing an excellent success in making contact. LESSON LEARNED: For hospitals not provided with an discharge outpatient clinic, post-discharge search is required and, among other methodologies, telephone contact is which seems to be the most accurate, since it covers almost all patients. The infection rate identified after discharge in this study justifies implementing this type of vigilance, always assessing the feasibility and costs of each methodology employed.
Publication Number 3-149 The Hematology/Oncology (Hem/Onc) Central-line Associated Bloodstream Infection (CLABSI) Rates Are Impacted by the 2013 National Health Safety Network (NHSN) Definitions Yolanda Ballam BS, CIC, Infection Prevention and Control Practitioner, Children’s Mercy Hospital and Clinics; Christelle Ilboudo MD, Pediatric Infectious Diseases Fellow, Children’s Mercy; Cindy Olson-Burgess RN, CIC, Director, Infection Prevention and Control, Children’s Mercy Hospitals and Clinics ISSUE: Discussions regarding CLABSI rates in the Heme/Onc population suggest that many CLABSIs may be due to translocation of intestinal or oral flora from mucosal barrier injury (MBI). Healthcare facilities reporting data to NHSN began using revised definitions for CLABSI in January 2013 including a more specific category for MBI bloodstream infections (BSI). PROJECT: Our objective was to apply the 2013 NHSN CLABSI definitions to Hem/Onc CLABSIs from 2012 to demonstrate the impact of a definition change on CLABSI rates in this population. Using our existing infection control databases, patients were categorized by primary diagnosis as well as whether the 2012 CLABSIs met the 2013 criteria for a mucosal barrier injury BSI. Any BSIs meeting the criteria for MBI BSI were excluded in the recalculated CLABSI rates. RESULTS: Applying the new definitions, 14 BSIs previously categorized as CLABSIs in 2012, were now classified as MBI related BSIs. All 14 met the criteria for neutropenia. One CLABSI failed to meet the new specified time frame for common commensal isolates. Our total CLABSI Number of 33 dropped to 18 resulting in a 45% decrease in CLABSI rates, from 5.54/1000 line days to 3.02/1000 line days. Of the 14 meeting the new MBI definition, 5 had a diagnosis of ALL, 6 AML and 3 other varied diagnosis. LESSON LEARNED: Our 354 bed free-standing pediatric hospital has a 36 bed Hem/Onc unit. Applying the 2013 definitions to this population showed a 45% reduction in CLABSI rates. 42% of previously reported CLABSIs fit the definition for MBI BSI. The new definitions reflect a more accurate CLABSI rate in this population and provide for specific targeted interventions in reducing total BSIs.
Publication Number 3-150 Improving the Practice of Tattooing in Radiation Oncology Susanne Stone RN, BSN, CIC, Infection Prevention Analyst, Montefiore Medical Center; Audrey Adams RN, MPH, CIC, Director of Infection Prevention and Control, Montefiore Medical Center; Marianne Cintron ARRT, Assistant Chief Therapist Radiation Oncology, Montefiore Medical Center ISSUE: Two thirds of cancer patients will receive radiation therapy (RT) during their illness. Once the physician defines the area of treatment, permanent marks are placed on the patient to serve as reference points as well as improve the reproducibility of the daily set-up. These permanent marks are traditionally tattoos. Our 750-bed teaching hospital scans approximately 10-14 patients daily, amongst its two Radiation Oncology facilities, in preparation for RT. All patients receiving a course of external Radiation Therapy will be permanently marked with tattoos. This translates into almost 2400 patients per year receiving multiple (3-6) pinprick tattoos at our facilities. PROJECT: While providing an Infection Prevention in-service to our Radiation Oncology Department, needle safety was reviewed related to tattooing. There was concern that potential breaks in standard precautions could occur in our patient population receiving tattoos. This finding provided an opportunity to improve the following practice Issues: Skin was not prepped prior to tattooing; a general use “sharpie” was used as an initial marking device, not a single use marker, as dictated in the OR setting; the non-safety needle used for permanent marking could potentially lead to needlesticks, and multi-dose ink was used, with potential for contamination. RESULTS: Infection Prevention worked with the Radiation Oncology team to develop improvement protocols, including single use markers. Also, manufactured needles with pre-filled ink were obtained, providing better tattoo needles with a single use device. A written policy is being developed that is realistic and safe for the patient and the healthcare provider. LESSON LEARNED: The Infection Preventionist must be vigilant at all times to identify opportunities to improve infection prevention practices. Although there is limited literature on tattoo infections in the community arena, there is even less information in the healthcare setting. The importance of standard hygienic tattoo practice should not be diminished. The development of national guidelines and/or recommendations should be considered.
Publication Number 3-151 Issues Associated with Infection Control and Prevention in Nursing Homes in Japan Kimiyo Nanke, Assistant Professor, Department of Nursing/Faculty of Life Sciences/Kumamoto University; Hitomi Maeda PhD, Professor, Department of Nursing/Faculty of Life Sciences/ Kumamoto University ISSUE: Japanese medical care reform promotes early transfer of patients from hospitals to either nursing homes or home; therefore, this increases the dependence on health care and risk of infection at elderly care facilities. Accordingly, the incidence of infectious outbreaks at elderly care facilities is higher, therefore, this necessitates improvements in infection control and prevention at nursing
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014
Poster Abstracts / American Journal of Infection Control 42 (2014) S29-S166
homes. This research aimed to clarify Issues associated with infection control and prevention at nursing homes. PROJECT: Questionnaires were mailed to 2193 nursing homes randomly selected throughout Japan from January to February, 2013; of these, 409 (18.7 %) returned valid responses. The questionnaires enquired the regarding types of infectious disease during the past 5 years in the facilities, and the existing problems associated with infection control and prevention when patients transferred from other facilities. Responses were coded to prevent misinterpretations of descriptions; these were categorized according to similarities. RESULTS: During the past 5 years, influenza and infectious gastroenteritis were reported in 64.8% and 54.5% facilities, respectively. Of the facilities, 37.2% reported Issues regarding infection control and prevention when patients transferred from other facilities. Examples of such Issues included the following: “inspection expenses need to be covered by the facility itself”, “several patients have dementia and several rooms are shared, therefore, isolation is difficult”, “lack of experience and knowledge of infection control and prevention make it difficult for the staff to practice standard precautions” and “delivery of information from previous hospitals or other facilities is insufficient.” LESSON LEARNED: Japanese nursing homes possess fewer medial workers and are designed for group living; therefore, infections are easily spread. Thus, it is important to obtain correct information and practices based on evidence. This research finding suggested an information-sharing method among hospitals and other facilities, staff education to promote standard precautions and infection assessment ability, and infection inspection system at patient transfer including cost-sharing of inspections should be immediately developed.
Publication Number 3-152 Usefulness of PDCA Tool as a Means of Implementing a Plan for Reduction of Catheter-related Bloodstream Infection Rates in ICU Cristiane Schmitt, Master in Science, Infection Control Nurse, Ph.D Student - Department of Medical-surgical Nursing, University of Sao Paulo; Icaro Boszczowski MD, MSc, Hospital Epidemiologist - Infection Control Department, Hospital Alemão Oswaldo Cruz and Hospital das Clínicas, University of Sao Paulo; Amanda Luiz Pires Maciel RN, Infection Control Nurse RN, Hospital Alemão Oswaldo Cruz; Marcia Baraldi, Infection Control Nurse, Hospital Alemão Oswaldo Cruz; Cristiane Santoro, ICU Nurse, Hospital Alemão Oswaldo Cruz; Fernando Colombari, ICU Physician, Hospital Alemão Oswaldo Cruz; Maritza Cantarelli, Infection Control Physician, Hospital Alemão Oswaldo Cruz ISSUE: Central line-associated bloodstream infection (CLABSI) are associated to high mortality and increased costs in health care. We identified in our intensive care unit (ICU) incidence of 4,5 CLABSI per 1000 catheters-day in twelve months (5/12 a 4/13). This study aims to demonstrate how a quality tool (PDCA) can contribute to the decrease of these events. Our primary goal is to reduce CLABSI by 80% in twelve months (5/13 a 4/14). PROJECT: We used PDCA (Plan, Do, Check and Action). Plan phase had three steps: 1) brainstorming to explore problems during insertion and maintenance of CVC; 2) structured audit (prevalence) to diagnose problems in everyday practice 3) based on brainstorming and audit findings we planned an intervention. Do phase consisted of: a) daily audits of CVC maintenance during rounds; b)
S53
training on CVC care; c) developing a visual communication campaign; d) monthly meetings with ICU team to discuss rates and process indicators. Check phase is our monthly evaluation of CLABSI incidence. Action phase will be performed at the end of cycle. RESULTS: Poor knowledge about routines of CVC care and lack of an insertion kit were pointed out during brainstorming. Audits found that 38% (9/24) of dressings were inadequate and 25% (6/24) of charts did not describe the aspect of insertion site. We observed 98% of adequacy during 117 CVC insertions. An insertion kit was provided. We trained 178 (75.7%) professionals of nursing staff and 57 (24.3%) physicians on good practices. Colorful posters were attached every month in ICU wall boards. We achieved so far a 58% reduction in CLABSI incidence. We have fulfilled seven months of the proposed cycle until now. LESSON LEARNED: PDCA proved to be helpful in organizing action plans to achieve a consistent reduction in CLABSI incidence. It is an objective way to understand to what extent the multifactorial Issues of infection control and prevention are lacking in one facility and to plan focused actions based on scientifically consistent evidence according to specific identified needs.
Publication Number 3-153 A Designated Dressing Change Team Significantly Reduces Catheter Related Bloodstream Infections in a Long-term Acute Care Facility Within Three Months MarCia Ekworomadu MPH, CIC, Infection Preventionist, Infection Prevention and Management Associates ISSUE: The catheter related blood stream infection (CRBSI) rate in a long term acute care hospital (LTACH) increased above the national benchmark and continually averaged above benchmark for one year before reaching zero. LTACH settings are especially vulnerable to CRBSIs because patients are admitted with complex medical needs, resulting in multiple venous access coupled with multiple co-morbidities (Munoz-Price, Clin Infect Dis. 2009). This abstract describes a systematic intervention to a persistent increase of CRBSIs in a LTACH. PROJECT: A comparison of all CRBSI events was completed assessing several risk factors and/or exposures. Those chosen to be included in the intervention were hand/patient hygiene, isolation practices and central venous catheter utilization and maintenance. Beginning October 2012 supplementary staff education, isolation chart stickers and additional hand hygiene dispensers were added throughout the facility. Furthermore, Chlorohexidine bathing frequency was increased in the intensive care unit (ICU). To address CVC maintenance and utilization, a five person dressing change team (DCT) was initiated and used to measure the Institute for Healthcare Improvement (IHI) CRBSI bundle compliance. RESULTS: Fisher’s exact test was used to analyze the data. Within three months of the intervention initiation the housewide CRBSI rate reached below the national benchmark. The CRBSI rate during the first three months of the intervention (Sep 2012-Nov 2012) was 5.33 per 1000 catheter days (CD) (22/4126) as compared to 1.79 per 1000 CD (6/3338) during the first three months of the DCT intervention (Dec 2012-Feb 2013) [p¼0.013]. Within the first three months of initiating the DCT the housewide CRBSI rate decreased 65% and a total of 100% within the 12 month intervention period (Sep 2012-Sep 2013).
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014
Poster Abstracts / American Journal of Infection Control 42 (2014) S29-S166
Post-discharge search is recommended by national legislation (RDC February 8, 2009) so as to identify mycobacterial infections after videosurgeries, conventional abdominal and pelvis surgeries, breast surgeries and liposuctions. This search was performed by telephone, using a standard questionnaire with signs and symptoms suggesting infection. After SSI was identified, the patient was informed and followed after 60 and 90 days to follow on outcome. RESULTS: 282 SSI were identified in intra-hospital environment and 104 cases were identified through post-discharge search, i.e., from the total SSI, 26.9% would not be noticed if there was not a post-discharge search. No case with suspected mycobacterial infection was identified. From 13245 patients undergoing surgery, 11968 (90.4%) were found and accepted to answer the questionnaire, showing an excellent success in making contact. LESSON LEARNED: For hospitals not provided with an discharge outpatient clinic, post-discharge search is required and, among other methodologies, telephone contact is which seems to be the most accurate, since it covers almost all patients. The infection rate identified after discharge in this study justifies implementing this type of vigilance, always assessing the feasibility and costs of each methodology employed.
Publication Number 3-149 The Hematology/Oncology (Hem/Onc) Central-line Associated Bloodstream Infection (CLABSI) Rates Are Impacted by the 2013 National Health Safety Network (NHSN) Definitions Yolanda Ballam BS, CIC, Infection Prevention and Control Practitioner, Children’s Mercy Hospital and Clinics; Christelle Ilboudo MD, Pediatric Infectious Diseases Fellow, Children’s Mercy; Cindy Olson-Burgess RN, CIC, Director, Infection Prevention and Control, Children’s Mercy Hospitals and Clinics ISSUE: Discussions regarding CLABSI rates in the Heme/Onc population suggest that many CLABSIs may be due to translocation of intestinal or oral flora from mucosal barrier injury (MBI). Healthcare facilities reporting data to NHSN began using revised definitions for CLABSI in January 2013 including a more specific category for MBI bloodstream infections (BSI). PROJECT: Our objective was to apply the 2013 NHSN CLABSI definitions to Hem/Onc CLABSIs from 2012 to demonstrate the impact of a definition change on CLABSI rates in this population. Using our existing infection control databases, patients were categorized by primary diagnosis as well as whether the 2012 CLABSIs met the 2013 criteria for a mucosal barrier injury BSI. Any BSIs meeting the criteria for MBI BSI were excluded in the recalculated CLABSI rates. RESULTS: Applying the new definitions, 14 BSIs previously categorized as CLABSIs in 2012, were now classified as MBI related BSIs. All 14 met the criteria for neutropenia. One CLABSI failed to meet the new specified time frame for common commensal isolates. Our total CLABSI Number of 33 dropped to 18 resulting in a 45% decrease in CLABSI rates, from 5.54/1000 line days to 3.02/1000 line days. Of the 14 meeting the new MBI definition, 5 had a diagnosis of ALL, 6 AML and 3 other varied diagnosis. LESSON LEARNED: Our 354 bed free-standing pediatric hospital has a 36 bed Hem/Onc unit. Applying the 2013 definitions to this population showed a 45% reduction in CLABSI rates. 42% of previously reported CLABSIs fit the definition for MBI BSI. The new definitions reflect a more accurate CLABSI rate in this population and provide for specific targeted interventions in reducing total BSIs.
Publication Number 3-150 Improving the Practice of Tattooing in Radiation Oncology Susanne Stone RN, BSN, CIC, Infection Prevention Analyst, Montefiore Medical Center; Audrey Adams RN, MPH, CIC, Director of Infection Prevention and Control, Montefiore Medical Center; Marianne Cintron ARRT, Assistant Chief Therapist Radiation Oncology, Montefiore Medical Center ISSUE: Two thirds of cancer patients will receive radiation therapy (RT) during their illness. Once the physician defines the area of treatment, permanent marks are placed on the patient to serve as reference points as well as improve the reproducibility of the daily set-up. These permanent marks are traditionally tattoos. Our 750-bed teaching hospital scans approximately 10-14 patients daily, amongst its two Radiation Oncology facilities, in preparation for RT. All patients receiving a course of external Radiation Therapy will be permanently marked with tattoos. This translates into almost 2400 patients per year receiving multiple (3-6) pinprick tattoos at our facilities. PROJECT: While providing an Infection Prevention in-service to our Radiation Oncology Department, needle safety was reviewed related to tattooing. There was concern that potential breaks in standard precautions could occur in our patient population receiving tattoos. This finding provided an opportunity to improve the following practice Issues: Skin was not prepped prior to tattooing; a general use “sharpie” was used as an initial marking device, not a single use marker, as dictated in the OR setting; the non-safety needle used for permanent marking could potentially lead to needlesticks, and multi-dose ink was used, with potential for contamination. RESULTS: Infection Prevention worked with the Radiation Oncology team to develop improvement protocols, including single use markers. Also, manufactured needles with pre-filled ink were obtained, providing better tattoo needles with a single use device. A written policy is being developed that is realistic and safe for the patient and the healthcare provider. LESSON LEARNED: The Infection Preventionist must be vigilant at all times to identify opportunities to improve infection prevention practices. Although there is limited literature on tattoo infections in the community arena, there is even less information in the healthcare setting. The importance of standard hygienic tattoo practice should not be diminished. The development of national guidelines and/or recommendations should be considered.
Publication Number 3-151 Issues Associated with Infection Control and Prevention in Nursing Homes in Japan Kimiyo Nanke, Assistant Professor, Department of Nursing/Faculty of Life Sciences/Kumamoto University; Hitomi Maeda PhD, Professor, Department of Nursing/Faculty of Life Sciences/ Kumamoto University ISSUE: Japanese medical care reform promotes early transfer of patients from hospitals to either nursing homes or home; therefore, this increases the dependence on health care and risk of infection at elderly care facilities. Accordingly, the incidence of infectious outbreaks at elderly care facilities is higher, therefore, this necessitates improvements in infection control and prevention at nursing
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014
Poster Abstracts / American Journal of Infection Control 42 (2014) S29-S166
homes. This research aimed to clarify Issues associated with infection control and prevention at nursing homes. PROJECT: Questionnaires were mailed to 2193 nursing homes randomly selected throughout Japan from January to February, 2013; of these, 409 (18.7 %) returned valid responses. The questionnaires enquired the regarding types of infectious disease during the past 5 years in the facilities, and the existing problems associated with infection control and prevention when patients transferred from other facilities. Responses were coded to prevent misinterpretations of descriptions; these were categorized according to similarities. RESULTS: During the past 5 years, influenza and infectious gastroenteritis were reported in 64.8% and 54.5% facilities, respectively. Of the facilities, 37.2% reported Issues regarding infection control and prevention when patients transferred from other facilities. Examples of such Issues included the following: “inspection expenses need to be covered by the facility itself”, “several patients have dementia and several rooms are shared, therefore, isolation is difficult”, “lack of experience and knowledge of infection control and prevention make it difficult for the staff to practice standard precautions” and “delivery of information from previous hospitals or other facilities is insufficient.” LESSON LEARNED: Japanese nursing homes possess fewer medial workers and are designed for group living; therefore, infections are easily spread. Thus, it is important to obtain correct information and practices based on evidence. This research finding suggested an information-sharing method among hospitals and other facilities, staff education to promote standard precautions and infection assessment ability, and infection inspection system at patient transfer including cost-sharing of inspections should be immediately developed.
Publication Number 3-152 Usefulness of PDCA Tool as a Means of Implementing a Plan for Reduction of Catheter-related Bloodstream Infection Rates in ICU Cristiane Schmitt, Master in Science, Infection Control Nurse, Ph.D Student - Department of Medical-surgical Nursing, University of Sao Paulo; Icaro Boszczowski MD, MSc, Hospital Epidemiologist - Infection Control Department, Hospital Alemão Oswaldo Cruz and Hospital das Clínicas, University of Sao Paulo; Amanda Luiz Pires Maciel RN, Infection Control Nurse RN, Hospital Alemão Oswaldo Cruz; Marcia Baraldi, Infection Control Nurse, Hospital Alemão Oswaldo Cruz; Cristiane Santoro, ICU Nurse, Hospital Alemão Oswaldo Cruz; Fernando Colombari, ICU Physician, Hospital Alemão Oswaldo Cruz; Maritza Cantarelli, Infection Control Physician, Hospital Alemão Oswaldo Cruz ISSUE: Central line-associated bloodstream infection (CLABSI) are associated to high mortality and increased costs in health care. We identified in our intensive care unit (ICU) incidence of 4,5 CLABSI per 1000 catheters-day in twelve months (5/12 a 4/13). This study aims to demonstrate how a quality tool (PDCA) can contribute to the decrease of these events. Our primary goal is to reduce CLABSI by 80% in twelve months (5/13 a 4/14). PROJECT: We used PDCA (Plan, Do, Check and Action). Plan phase had three steps: 1) brainstorming to explore problems during insertion and maintenance of CVC; 2) structured audit (prevalence) to diagnose problems in everyday practice 3) based on brainstorming and audit findings we planned an intervention. Do phase consisted of: a) daily audits of CVC maintenance during rounds; b)
S53
training on CVC care; c) developing a visual communication campaign; d) monthly meetings with ICU team to discuss rates and process indicators. Check phase is our monthly evaluation of CLABSI incidence. Action phase will be performed at the end of cycle. RESULTS: Poor knowledge about routines of CVC care and lack of an insertion kit were pointed out during brainstorming. Audits found that 38% (9/24) of dressings were inadequate and 25% (6/24) of charts did not describe the aspect of insertion site. We observed 98% of adequacy during 117 CVC insertions. An insertion kit was provided. We trained 178 (75.7%) professionals of nursing staff and 57 (24.3%) physicians on good practices. Colorful posters were attached every month in ICU wall boards. We achieved so far a 58% reduction in CLABSI incidence. We have fulfilled seven months of the proposed cycle until now. LESSON LEARNED: PDCA proved to be helpful in organizing action plans to achieve a consistent reduction in CLABSI incidence. It is an objective way to understand to what extent the multifactorial Issues of infection control and prevention are lacking in one facility and to plan focused actions based on scientifically consistent evidence according to specific identified needs.
Publication Number 3-153 A Designated Dressing Change Team Significantly Reduces Catheter Related Bloodstream Infections in a Long-term Acute Care Facility Within Three Months MarCia Ekworomadu MPH, CIC, Infection Preventionist, Infection Prevention and Management Associates ISSUE: The catheter related blood stream infection (CRBSI) rate in a long term acute care hospital (LTACH) increased above the national benchmark and continually averaged above benchmark for one year before reaching zero. LTACH settings are especially vulnerable to CRBSIs because patients are admitted with complex medical needs, resulting in multiple venous access coupled with multiple co-morbidities (Munoz-Price, Clin Infect Dis. 2009). This abstract describes a systematic intervention to a persistent increase of CRBSIs in a LTACH. PROJECT: A comparison of all CRBSI events was completed assessing several risk factors and/or exposures. Those chosen to be included in the intervention were hand/patient hygiene, isolation practices and central venous catheter utilization and maintenance. Beginning October 2012 supplementary staff education, isolation chart stickers and additional hand hygiene dispensers were added throughout the facility. Furthermore, Chlorohexidine bathing frequency was increased in the intensive care unit (ICU). To address CVC maintenance and utilization, a five person dressing change team (DCT) was initiated and used to measure the Institute for Healthcare Improvement (IHI) CRBSI bundle compliance. RESULTS: Fisher’s exact test was used to analyze the data. Within three months of the intervention initiation the housewide CRBSI rate reached below the national benchmark. The CRBSI rate during the first three months of the intervention (Sep 2012-Nov 2012) was 5.33 per 1000 catheter days (CD) (22/4126) as compared to 1.79 per 1000 CD (6/3338) during the first three months of the DCT intervention (Dec 2012-Feb 2013) [p¼0.013]. Within the first three months of initiating the DCT the housewide CRBSI rate decreased 65% and a total of 100% within the 12 month intervention period (Sep 2012-Sep 2013).
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014